Psychosis in Older Adults

Psychosis by definition is an impairment of reality testing causing cognitive and behavioural disturbances and often manifested as delusions (abnormal thoughts) and/or hallucinations (abnormality in senses).

Psychotic symptoms are more common in population of older adults than in younger people, this is due to the fact that ‘medical conditions’ such as delirium and dementia can have associated psychotic symptoms. Both delirium and dementia rise with age. The other contributing factors are neurochemical changes associated with aging, social isolation, sensory impairments (poor eye sight, deafness ) and polypharmacy (most older adult have at least two medications for physical health issues and the number of medications taken by older adults increase with age). At least 23% of older adults will experience psychotic symptoms at some point in life.

“At least 23% of older adults will experience psychotic symptoms at some point in life.”

What are the causes of psychosis in older adults?

Acute onset is usually seen in delirium secondary to medical conditions, drug misuse and drug-induced psychosis. Chronic and persistent psychotic symptoms may be due to primary psychotic disorder (chronic schizophrenia, late-onset schizophrenia, delusional disorders, mood disorders), and psychosis due to neurodegenerative disorders (dementias, Parkinson’s disease) and chronic medical conditions.

It is important to recognise psychotic symptoms and treat them at the right time as they can lead to aggressive and disruptive behaviour and are often a source of distress to caregivers. Persistent symptoms decrease quality of life, leads to hospital admission or institutionalisation. In some cases may result in neglect and abuse of older person.

Schizophrenia: Older people with schizophrenia have traditionally been divided into two main groups, those who develop the illness in later life and those have had from an early age and have now grown old. The late onset can be further divided into those developing after 40yrs of age and those after 60 yrs of age (very late onset schizophrenia).

There are certain similarities between early and late-onset schizophrenia, notably, both have genetic risks, present with subtle change in the brain as revealed by the scans and have delusions & hallucinations. The late-onset schizophrenia is dissimilar to early onset in the way that, there is good response to medication and they have better overall cognitive functions.

The very late-schizophrenia appears to affect more women than men, seen in people with sensory deprivation, those who are socially isolated, they have more delusion and hallucinations and response to medication may not be good.

Dementia: The prevalence of psychosis in people with dementia range from 30-50% in Alzheimer’s and Vascular dementia. Visual (seeing things in the absence of a stimuli) and auditory hallucinations (hearing things in the absence of a stimuli) are the most common. The four common type of misidentifying delusions seen are the capgras syndrome (previously known people replaced by strangers), the phantom border syndrome (guests are living in the house), the mirror sign (seeing his or her own mirror image as someone else) and the TV sign (images on the TV appears to be real).

Dementia of Lewy bodies and Parkinson’s disease dementia are believed to be disorders of the same spectrum, and require careful management of treatment as they are complex, more sensitive to antipsychotic medications than others and present with behavioural difficulties. Visual hallucinations are reported in 80% cases.

Other causes of Psychosis: Delirium which presents with hallucinations and delusion, in 30-40% cases due to medications, underlying medical conditions or poor hydration. Delusions and hallucinations are also seen alcohol abuse, Mood disorders (depression or bipolar disorders) and personality disorders in older adults.

Treatment

Treatment of psychosis obviously depends on what condition is being treated.

Psychosocial interventions are key- safety concern (minimising risks), validating approach(as experience of delusion and hallucinations are very real for the patient extreme sensitivity is required to explain their validity) , education for patient and family/caregivers.

Pharmacological treatments are reserved for patients who are significantly distressed and their functions are significantly affected. Newer antipsychotics are preferred and used with extreme care, in the short-term with regular review and consultation. Anticholiestearases (memory enhancers) are also showing encouraging results in treatment of delusion and hallucinations. Families and care givers should be informed and involved in the treatment plan.